High School Students in a PSU Laboratory/Site
This procedure establishes required measures to be taken when a high school student is being considered for work in a Penn State laboratory, or other specialized location, ensuring that s/he has received the appropriate instruction and has parental consent.
1. Faculty Sponsorship: The student must be sponsored/supervised by a member of the Penn State University faculty. This faculty sponsor is responsible for ensuring that this procedure is completed and that the student's activities are supervised closely.
2. Parental Consent: The student's parent or guardian must complete the Parental Consent Statement and Insurance Documentation form and submit it to the sponsoring faculty.
3. The faculty Sponsor must also ensure that the student's activities will not include direct work with:
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o Corrosive materials
o Toxic chemicals, including carcinogens
o Radioactive materials
o Flammable liquids
o Infectious agents
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4. There is to be no one-on-one contact between the student and the sponsoring faculty including direct electronic contact. There must always be two adults present.
5. Penn State Employees/Volunteers/Independent Contractors interacting with high school students are required, by law, to have the 3 publicly-available background clearances on file within their respective HR unit. Instructions for completing these clearances can be found at: http://www.universityethics.psu.edu/sites/universityethics/files/9-1-15-updated-background-clearance-instructions.pdf
6. Penn State Employees/Volunteers/Independent Contractors interacting with high school students are required to participate in the Building a Safe Penn State: Reporting Suspected Child Abuse training prior to interacting with minors. Instructions found at: http://www.universityethics.psu.edu/UniversityEthics/Training/index.cfm)
7. The sponsoring faculty is responsible for making all arrangements for students to receive all appropriate training. Students may begin work only after all training has been completed.
8. Laboratory Safety Approval: The sponsoring faculty must complete the Proposal for High School Student to Conduct Research or Work (Paid or Unpaid) in a Laboratory/Department form. When the Department Chair has signed the proposal, the sponsoring faculty sends the completed form, along with the completed parental consent form, to those individuals listed at the end the “proposal” form.
9. Approval must be resubmitted if there are any substantial changes in the activities or scope of work.
10. Copies of all forms are to be to be kept on record by the Head of the Laboratory.
11. When collaborating with a local high school training program, the high school is required to coordinate with the Associate Dean of the identified Department.
12. If you have any further questions, please contact Environmental Health and Safety at 814-865-6391 or PSU Youth Programs at 814-865-8785.
High School Students in a PSU Laboratory/Site
Parent Consent Statement and Insurance Documentation
PLEASE PRINT
Student’s Last Name: First Name: ______Date of Birth: ______
Name of Head of Laboratory/Head of Department: ______
Address: City: State: Zip:
Term of Internship: ______
Research Starting Date: ______Concluding Date: ______
Additional Personal Information
Student’s Address: City: ___ State: Zip:
Home Phone: E-mail Address: ______
Parent/Guardian #1: Parent/Guardian #2:
Daytime Phone: Daytime Phone:
Place of employment: Place of employment:
Health Insurance Carrier: Policy Number:
Plan Number: _ Is physician authorization needed? q Yes q No
Name of Family Physician: Phone:
In case of emergency, please notify:
If neither parent nor guardian is available in an emergency, please contact:
1. Phone:
2. Phone:
My child has been offered the opportunity to work (either paid or unpaid) at Penn State University. I understand that laboratories, and other locations, are specialized environments involving the use of scientific instrumentation, chemicals and biological materials, which even under ideal laboratory conditions may involve greater risk if used improperly. My child will be required to attend a laboratory safety instruction and will be taught and supervised in the proper handling of such instrumentation and materials to minimize risk. Knowing the circumstances and risks described above, and in consideration of permission for my child to work in the above-referenced PSU laboratory/other specialized location, I agree, on behalf of myself and my family, to my child’s working in the Penn State University laboratory.
In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be reached, I give my consent for physicians and staff at University Health Services or other licensed practitioners of the healing arts to perform any necessary emergency treatment. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. I understand that University Health Services does charge for services and that it is my responsibility to pay the bill if a claim can’t be submitted by the University Health Services to my private insurance. As applicable, I may be responsible to submit any claims to my health insurance company for reimbursement. I authorize The Pennsylvania State University to receive medical/billing information and submit it to the University’s insurance carrier.
I understand that, unless specifically stated otherwise, The Pennsylvania State University does not provide medical insurance to cover emergency care or medical treatment of my child.
HIPAA
Penn State honors the privacy of the participants in its Programs and complies with the national regulations regarding health information. Follow this computer link to the University Health Services Notice of Privacy Practices. http://studentaffairs.psu.edu/health/welcome/confidentiality/noticeOfPrivacyPractices.shtml)
Date: ______
Parent/Guardian (please print) Parent/Guardian Signature
Date: ______
Witness (please print) Witness Signature
Proposal for High School Student to Conduct Research or Work (paid or unpaid) in a PSU Laboratory/Site
PLEASE PRINT
Student’s Last Name: First Name: ______Date of Birth: ______
Current High School: ______School Contact Name: ______
Address: ______City: ______State: Zip: ______
Description of project the above student will be doing: ______
______
Is the lab experience for (please check one): ¨ Academic Credit ¨ For Payment ¨ Volunteer Experience
Please provide a summary of techniques this student is likely to use, as well as the materials and equipment which require particular care; these should be discussed with the student:
Techniques: ______
Materials and Equipment: ______
NOTE: Significant changes in the activities or scope of work described above will require re-submission
Does your laboratory use:
Radioactive materials yes ¨ no ¨ Carcinogenic substances yes ¨ no ¨
Toxic & hazardous substances yes ¨ no ¨ Corrosive materials yes ¨ no ¨
Flammable substances yes ¨ no ¨ Lasers yes ¨ no ¨
Infectious agents yes ¨ no ¨ Lab animals yes ¨ no ¨
Other hazards/concerns: ______
Please describe any involvement the student might have with any of the above: ______
______
Please describe the student’s past lab science courses, lab experience, worksite experience, etc.: ______
______
Date: ______
Department Chair Name (please print) Department Chair Signature
Date: ______
Sponsoring Faculty Member (please print) Sponsoring Faculty Member Signature
Date: ______
High School Contact (please print) High School Contact Signature
Please return completed forms to: EHS, 6 Eisenhower Parking Deck, University Park, PA
Head of Laboratory/Department identified above, Penn State University, University Park, PA 16802
Risk Management, Suite 103, Rider Building II, State College, PA 16801
Youth Program Compliance, 333 James Elliott Building, State College, PA 16801
High School Contact at the identified address
Sponsoring College Associate Dean for Undergraduate Education
Other: ______
Parent/Guardian consent form received yes ¨ no ¨ Student Safety Training completed yes ¨ no ¨
Evidence of student’s health insurance yes ¨ no ¨ Project Approved yes ¨ no ¨
______Date: ______
EHS Authorization By: Name/Title (please print) EHS Authorization Safety Officer Signature
EHS to send final, signed approval back to the five offices listed above.
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